Newly diagnosed woman often struggle with the surgical choice between a lumpectomy/wide excision and mastectomy. Most of the time, there is no difference in survival statistics or recurrence risk. Sometimes, due to the size or location of the tumor or if it occurs in a previously radiated breast, a mastectomy is recommended or inevitable.
Here is a discussion with Dr. Julie Gralow from the University of Washington about talking with your doctor re this decision:
ASCO Expert Corner: Talking With the Doctor About Lumpectomy or Mastectomy
For early-stage breast cancer, doctors generally recommend surgery to remove the tumor. Some women can choose between two types of surgery: a lumpectomy or mastectomy, although lumpectomy is not always a recommended option. A lumpectomy is the removal of the tumor and a small, clear (cancer-free) margin of tissue around the tumor. Radiation therapy is given after a lumpectomy to help reduce the risk of the cancer returning. A mastectomy is the removal of an entire breast. Although the long-term survival of women is the same for a lumpectomy or mastectomy, there are pros and cons for each option, making this a difficult decision for some women. To help women talk with their doctors about this decision, Cancer.Net spoke with Julie Gralow, MD.
Q: What information should a woman share with her doctor when deciding between a lumpectomy or mastectomy?
A: If a woman has a clear preference for the type of breast surgery, she should clearly express that to her health care team. There are women who feel strongly (either negatively or positively) about both of the choices, and doctors shouldn't assume they know what the patient wants. There are some women who don't have a strong preference either way. Most women are aiming for the best chance at cure—never having to deal with this cancer again.
Q: What are the advantages and disadvantages for a woman choosing lumpectomy followed by radiation therapy?
A: The advantage of lumpectomy is that the breast is preserved, which can have a favorable effect on body image for many women. The disadvantages include the need for radiation therapy (about six weeks, although we're studying shorter durations), and a higher rate of in-breast recurrence (return of cancer). Some of that in-breast recurrence is due to the fact that normal breast tissue remains and a second breast cancer can develop years later (it can do so in the other breast, too). Other recurrences are due to the same cancer coming back. With good surgery (clear margins, with no tumor at the edges) and radiation therapy, the risk of the same tumor returning should be low, but it is still higher than with mastectomy. It's very important to stress that survival and deaths due to breast cancer are not higher in women who choose lumpectomy, however. Another disadvantage of lumpectomy is that sometimes, after review of the surgical pathology report, further surgery may be recommended to clear remaining tumor from the breast. This could be a re-excision, which isn't guaranteed to be successful (meaning even another surgery could be recommended), or even a mastectomy.
Q: What are the advantages and disadvantages for a woman choosing a mastectomy?
A: The disadvantage of mastectomy is that it removes the breast, which can have a real emotional, in addition to physical, impact. The good news is that there are increasingly good reconstruction and prosthesis options. The advantage of mastectomy is that radiation therapy can be avoided in many (but not all) cases, and the rate of recurrences in the chest wall, while not zero, is quite low.
Q: What are some factors that play a role in a woman's choice between these procedures?
A: Body image can play a big role for some women, who feel very strongly that they want to make every attempt to retain the breast. Other women express wanting to avoid dealing with follow-up imaging of that breast, and the chance that more biopsies (removal of tissue for examination under a microscope) will be needed or a recurrence will be found, so they prefer to undergo mastectomy.
Q: What are some questions for women to ask their doctors?
A: Women considering lumpectomy should ask their surgeons how likely it is that the first surgery will be able to clear all of the cancer (what's the chance that they'll need another surgery?). Is there more imaging that should be done to help in surgical planning, to help evaluate for additional spread or sites of cancer? Also, they should ask for a good evaluation of what the in-breast recurrence will be predicted to be with a lumpectomy plus radiation therapy versus a mastectomy. This can be impacted by the size of the cancer, the aggressiveness, whether it involves the lymph nodes, and other features. Women considering mastectomy should consider speaking to a reconstructive surgeon before making their choice to understand their options. Sometimes reconstruction can be performed at the same time as the mastectomy, while other times it's recommended that the reconstruction be delayed.
Q: What other actions might be helpful for a woman to take during this time to help reach a decision?
A: Seeking a second opinion or an appointment with a reconstructive surgeon might be helpful. Sometimes women who have undergone reconstruction are willing to talk about the surgery and maybe even show their results (ask the reconstructive surgeon's office about that possibility). Members of support groups (or friends and family members) who have gone through the same choice themselves might be helpful in weighing the pros and cons.
Q: What are some important messages for women about this decision?
A: The decision about lumpectomy versus mastectomy is a very personal one. Friends and family may have helpful input and experiences to relate, but ultimately the choice has to be what feels right for the individual woman. Surgery after a diagnosis of breast cancer is usually never an emergency. If it takes a few weeks to get a second opinion or see a plastic surgeon in order to make the best decision, that's OK.
Dr. Gralow is Professor of Medicine/Oncology at the University of Washington School of Medicine and Fred Hutchinson
Cancer Research Center in Seattle. She serves as Cancer.Net's Associate Editor for breast cancer and is a past chair of ASCO's Cancer Communications Committee.